Program Manager - Clinical Denials

Philippines·Quezon CityFull-timemid

OperationsProject Manager

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Quick Summary

Key Responsibilities

Program Strategy & Governance Develops and executes the strategic roadmap for clinical denial management programs. Establishes program goals, KPIs, governance structures, and performance standards.

Requirements Summary

Required Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field. Active RN license or applicable clinical credential.

Technical Tools

OperationsProject Manager

Requirements

~1 min read

Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field.
Active RN license or applicable clinical credential.
7+ years of healthcare experience, with substantial experience in clinical denials, CDI, RCM, utilization management, appeals, or reimbursement.
3+ years of progressive leadership/management experience.
Demonstrated experience managing large-scale programs, multiple teams, or complex client engagements.
Strong understanding of inpatient DRG, medical necessity, level of care, clinical validation, coding, reimbursement, and payer policies.
Demonstrated financial and analytical acumen.
Excellent executive communication, presentation, negotiation, and stakeholder-management skills.

Nice to Have

~1 min read

CDAS or equivalent denial management credential.
CCDS/CDIP or equivalent CDI certification.
Master's degree such as MHA, MBA, MSN, or related discipline.
Experience with enterprise RCM transformation.
Experience with Epic, payer portals, denial analytics, and business intelligence platforms.
Experience managing multi-hospital or multi-client programs.
Experience with automation, AI, analytics, or technology-enabled denial management.

Responsibilities

~1 min read

Develops and executes the strategic roadmap for clinical denial management programs.
Establishes program goals, KPIs, governance structures, and performance standards.
Oversees multiple teams, managers, and/or client programs.
Ensures alignment between clinical denial strategy and organizational revenue cycle objectives.
Develops standardized operating models, workflows, and best practices.

Owns program-level denial recovery and financial performance.
Monitors gross and net revenue opportunity, dollars at risk, recovery rate, overturn rate, and denial inventory.
Develops strategies to maximize reimbursement and reduce revenue leakage.
Supports financial forecasting, business cases, and resource planning.
Identifies opportunities for automation, technology, and workflow optimization.

Provides subject-matter leadership for complex clinical denial categories.
Establishes enterprise strategies for medical necessity, DRG, level-of-care, clinical validation, documentation, and payer-specific denials.
Reviews emerging payer policies and reimbursement changes.
Develops strategies for high-value and systemic denial issues.
Partners with clinical and revenue cycle leadership to address root causes.

Serves as senior operational contact for assigned clients and programs.
Leads executive-level business reviews and performance discussions.
Presents program performance, financial outcomes, trends, risks, and strategic recommendations.
Manages client expectations and escalations.
Identifies opportunities for program expansion and additional value creation.

Leads enterprise-wide denial prevention initiatives.
Uses data analytics to identify systemic denial drivers.
Partners with CDI, HIM, coding, utilization management, clinical operations, finance, and billing leadership.
Develops corrective action and prevention strategies.
Measures the financial and operational impact of prevention initiatives.
Leads transformation projects involving technology, analytics, automation, and workflow redesign.

Provides leadership to Managers, Team Leads, and clinical denial professionals, a team size of minimum 50+.
Establishes leadership development and succession-planning strategies.
Promotes a culture of accountability, continuous improvement, and client service.
Ensures appropriate staffing models and organizational structures.
Oversees competency and training programs.

Ensures programs operate in accordance with regulatory requirements, payer policies, contractual obligations, and organizational standards.
Monitors emerging regulatory and reimbursement changes.
Identifies operational and financial risks and develops mitigation strategies.